Haryana

Karnal

CC/670/2021

Shakuntla Devi - Complainant(s)

Versus

HDFC ERGO General Insurance Company Limited - Opp.Party(s)

Balraj Pal

30 Oct 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                      Complaint No. 670 of 2021

                                                      Date of instt.01.12.2021

                                                      Date of Decision:30.10.2023

 

Shakuntla Devi wife of late Shri Tajinder Kumar son of Shri Satpal, resident of ward no.9, Maya Ram Colony, Railway Road, Taraori, District Karnal.

 

                                               …….Complainant.

                                              Versus

 

1. HDFC ERGO General Insurance Company Limited, 2^nd floor, SCO no.237, Sector-12, Urban Estate, Karnal.

 

2. HDFC Bank Ltd. Saunkara Road, Taraori, District Karnal through its Manager.

 

…..Opposite Parties.

       

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik…….Member

              Dr. Suman Singh……Member

          

Argued by:  Shri Balraj Pal,, counsel for the complainant.

                    Shri Sanjeev Vohra, counsel for the OP no.1.

                    OP no.2 exparte (vide order dated 10.06.2022).

 

                    (Jaswant Singh, President)

ORDER:                     

          

               The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that husband of complainant namely, Tajinder Kumar(since deceased) applied  a car loan with the OP no.2 and on the request of Tajinder Kumar a car loan amounting to Rs.3,31,761/- was sanctioned in which an amount of Rs.3,18,796/- was disbursed and he purchased a Maruti Wagon R car bearing registration no.HR05BE-6357. At the time of disbursement of loan amount, OP no.2 through OP no.1 got insured Tajinder Kumar under various heads and also secured the loan amount through “Sarv Suraksha +Master Policy no.2999203617346400 for the period from 22.01.2021 to 21.01.2026 and charged total premium amount of Rs.6761/-. At the time of advancement of loan, it was told by OPs that in case of untimely death of loanee due to any reason, the outstanding amount of loan will be waived off besides granting the compensation.

2.             Unfortunately, in the month of May 2021 husband of complainant got affected from covid-19 virus (critical illness) and he was admitted in Medanta-The medicity Gurugram Hospital on 12.05.2021 and during hospitalization, Tajinder Kumar further developed major various critical disease and thereafter died on 25.06.2021. After the abovesaid mis-happening OPs were informed and claim form was submitted and all relevant documents as required by the OPs were also submitted. It is further averred that neither the OP no.2 nor OP no.1 ever supplied detailed terms and conditions of the policy to insured at the time of insurance. Complainant approached the OPs so many times to OPs and requested to give claim benefit and make balance outstanding amount against car loan but OPs did not pay any heed to the request of complainant and lingered the matter on one pretext or the other and lastly repudiated the same, vide letter dated 04.08.2021 on the ground false and frivolous ground. At the time of insurance, OPs assured that entire loan amount will be waived off if insured died due to any reason as they had charged the premium under Credit Shield Insurance also covering the risk of entire loan amount. Then complainant sent a legal notice dated 16.09.2021 to the OPs but it also did not yield any result. In this there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OP no.1 to pay all the benefits of the Sarv Suraksha policy and to pay remaining loan amount against car loan and further pay sum of Rs.1,00,000/- insured amount under critical illness to complainant alongwith interest @ 24% per annum, to pay Rs.1,00,000/- on account of harassment, mental pain and agony and Rs.22,000/- towards the litigations expenses.

3.            On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that complainant filed a claim vide ID:RR-HS21-12534314 for the deceased Mr. Tajinder Kumar who was admitted in hospital for diagnosis of covid-19, Pneumonia on 12.05.2021 at Medanta Hospital, Gurugram. Post scrutiny of the documents submitted by the complainant, it was observed that the hospitalization of the insured was non-accidental in nature and as per section 3 and 5 of the policy provides coverage to accidental injury only during the policy period. Hence, the claim of complainant has rightly been repudiated (accident or accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent means) as per policy terms and condition. It is further pleaded that policy kit containing all relevant documents were duly received by the policyholder. Policyholder never approached the OP stating that any information given in the policy kit was incorrect or any terms and condition therein is not understandable or acceptable to him from the receipt of the policy document. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.            OP no.2 did not appear despite service and opted to be proceeded against exparte, vide order dated 10.06.2022 of the Commission.

5.            Parties then led their respective evidence.

6.            Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of application form Ex.C2, copy of email dated 04.08.2021 regarding repudiation of claim Ex.C3, copy of legal notice Ex.C4, copy of repayment schedule dated 02.11.2021 Ex.C5, copy of death summary Ex.C6, copy of aadhar card Ex.C7, copy of PAN card Ex.C8, copy of death certificate of Tajinder Kumar Ex.C9 and closed the evidence on 03.11.2022 by suffering separate statement.

7.            On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Manoj Kumar Prajapati Manager Ex.RW1/A, copy of repudiation letter Ex.R1, copy of reply of legal notice dated 20.09.2021 Ex.R2, copy of insurance policy Ex.R3 and closed the evidence on 25.05.2023 by suffering separate statement.

 8.            We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

9.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that Tajinder Kumar (since deceased) had taken a car loan of Rs.3,31,761/- from the OP no.2. At the time of disbursement of personal loan, OP no.2 through OP no.1 got insured Tajinder Kumar under Sarav Suraksha Policy for the period from 22.01.2021 to 21.01.2026. In the month of May 2021, Tajinder Kumar suffered from Covid-19 Virus and was admitted in Medanta-The Medicity Gurugram Hospital on 12.05.2021 and during hospitalization Tajinder Kumar developed major various critical illness and died on 25.06.2021. Intimation was given to the OPs and all the formalities were completed but OPs did not pay the benefits regarding the insurance policy and lastly prayed for allowing the complaint.

10.           Per contra, learned counsel for the OP no.1, while reiterating the contents of written version, has vehemently argued that insured had taken car loan the OP no.2. Insured Tajinder Kumar was admitted in hospital for diagnosis of covid-19, Pneumonia on 12.05.2021 at Medanta Hospital, Gurugram. From the scrutiny of the documents, it was observed that the hospitalization of the insured was non-accidental in nature and as per section 3 and 5 of the policy provides coverage to accidental injury only during the policy period. Insured died due to Covid-19, which is not covered as per policy. the claim of complainant has rightly been repudiated, as per policy terms and condition and prayed for dismissal of complaint qua OP no.1.

11.           Admittedly, Tajinder Kumar (since deceased) had availed a car loan from the OP no.2. It is also admitted that the said loan was got insured by the OP no.2 from OP no.1. It is also admitted that during the subsistence of the insurance policy, the insured was expired.

12.           The claim of the complainant has been repudiated by the OP no.1, vide repudiation letter Ex.C3/Ex.R1 dated 12.08.2021 on the ground, which is reproduced as under:-

“With reference to your email dated 3.08.2021, it is observed that the policy purchased by your goodself is “Sarv Suraksha Plan” which covers Accidental hospitalization, permanent total disability/permanent partial disability, critical illness etc.

The insured in this case has been admitted for treatment of covid pneumonia and succumbed to the complications of the disease at the hospital. As this event is not covered in the listed coverages in policy, the claim is not admissible.”

13.           The claim of the complainant has been repudiated by the OPs on the abovesaid ground.

14.           As per the terms and conditions of the insurance policy the critical illness are that:

i) First heat Attack

                ii) Coronoary Artery Disease Requiring surgery

               iii) Stroke,

               iv) Cancer

                v) Kidney Failure

vi) Major Organ Transplantation

vii) Multiple Sclerosis

 viii) Surgery of Aorta

 ix) Primary Pulmonary Arterial Hypertension

 x)Paralysis.

15.           The OPs have alleged that as the husband of the complainant has died due to Covid-19 and the covid does not fall under critical illness, as such, the benefit under the policy in question cannot be granted to the complainant. In this regard, we are of the considered view that the COVID 19 came in India in the beginning of 2020. In April 2021, severe acute respiratory syndrome Coronavirus has caused over 150 million cases of coronavirus disease 2019 (COVID-19) and over 3 million deaths occurred worldwide. The COVID-19 pandemic had been characterized by local surges of infection accompanied by tremendous demand for hospital and intensive care unit (ICU) resources. In parallel with these uniquely challenging conditions, knowledge around the treatment of this novel disease has accelerated rapidly. An estimated one-fifth to one-third of hospitalized patients with COVID-19 experience critical illness, with clinical decomposition at a median of 9 days from symptom onset and 3 days from hospital admission. Acute hypoxemic respiratory failure is the most common form of organ failure, contributing to over 90% of COVID-19-related deaths in ICU patients. Roughly in one-quarter of patients with COVID-19 critical illness requires , two-thirds require invasive mechanical ventilation (MV), two-thirds require vasopressor support, and one in six require renal replacement therapy. The crona virus is such a disease which can fail all the organs of the body in one or two days, then how, the OPs can say that this is not a critical illness.  It is more dangerous disease than the diseases mentioned in the column of critical illness in the terms and conditions of the insurance policy. Possibility of printing of Performa of terms and conditions of the policy much prior to coming of Covid-19, cannot be ruled out.   It has caused a huge tragedy in the world, rather, the disease which have been mentioned by the OPs in the terms and conditions of the policy, are less critical than the covid 19 virus. Hence, this plea taken by the OPs is having no force.

16.           As per insurance policy, the husband of complainant was covered for Rs.1,00,000/- as critical illness and Rs.5,00,000/- as credit shield insurance. Section 5 (Credit Shield Insurance policy) is reproduced as under:-

 

Coverage:

Credit Shield

In the event of accidental Death or Permanent Total Disability of the insured Person during the Policy Period, the company will make payment under this policy as detailed below:-

The company will pay the balance outstanding loan amount in the manner agreed in the name of the insured Person in the books of the Financer/Bank/Mortgage Company, subject to the maximum Sum insured specified in the Schedule. Claim will be directly paid to the Financer/Bank/Mortgage Company to the extent of outstanding loan amount.

The outstanding loan amount would not include any arrears of the borrower due to any reasons whatsoever. The claim to be settled only in respect of the death of the first named borrower and not in respect of the others, which may happen in case loan is taken jointly.

17.           As per above said Section the benefit of credit shield covers in the event of accidental death or permanent total disability but the husband of the complainant died due to COVID 19, as such, the complainant is not entitled for the benefit of Credit Shield Insurance, whereas, as the husband of the complainant died due to critical illness, hence she is entitled for Rs.1,00,000/- alongwith compensation on account of mental agony and litigation expenses.

 18.          Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OPs to pay Rs.1,00,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 12.08.2021 till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:30.10.2023

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

                (Vineet Kaushik)        (Dr. Suman Singh)    

                      Member                    Member